Does Flipping From Prone to Supine for Medial Malleolar Fixation of Trimalleolar Ankle Fractures Improve Results?

There has been a paradigm shift towards fixing the posterior malleolus in trimalleolar ankle fractures. This study evaluated whether a surgeon's preference to intraoperatively flip or not flip patients from prone to supine for medial malleolar fixation following repair of fibular and posterior malleoli impacted surgical outcomes. A retrospective patient cohort treated at a large urban academic center and level 1 trauma center was reviewed to identify all operative trimalleolar ankle fractures initially positioned prone. One hundred and forty-seven patients with mean 12-month follow-up were included and divided based on positioning for medial malleolar fixation, prone or supine (following closure, flip and re-prep, and drape). Data was collected on patient demographics, injury mechanism, perioperative variables, and complication rates. Postoperative reduction films were reviewed by orthopedic traumatologists to grade the accuracy of anatomic fracture reduction. Overall, 74 (50.3%) had the medial malleolus fixed prone, while 73 (49.7%) were flipped and fixed supine. No differences in demographics, injury details, and fracture type existed between the groups. The supine group had a higher rate of initial external fixation (p = .047), longer operative time in minutes (p < .001), and a higher use of plate and screw constructs for medial malleolar fixation (p = .019). There were no differences in clinical and radiographic outcomes and complication rates. This study demonstrated that intraoperative change in positioning for improved medial malleolar visualization in trimalleolar ankle fractures results in longer operative times but similar radiographic and clinical results. The decision of operative position should be based on surgeon comfort.

Surgical repair of large segmental bone loss with the induced membrane technique: patient reported outcomes are comparable to nonunions without bone loss.

OBJECTIVE: To compare the outcomes of patients with segmental bone loss who underwent repair with the induced membrane technique (IMT) with a matched cohort of nonunion fractures without bone loss. DESIGN: Retrospective analysis on prospectively collected data. SETTING: Academic medical center. PATIENTS: Two cohorts of patients, those with upper and lower extremity diaphyseal large segmental bone loss and those with ununited fractures, were enrolled prospectively between 2013 and 2020. Sixteen patients who underwent repair of 17 extremities with segmental diaphyseal or meta-diaphyseal bone defects treated with the induced membrane technique were identified, and matched with 17 patients who were treated for 17 fracture nonunions treated without an induced membrane. Sixteen of the bone defects treated with the induced membrane technique were due to acute bone loss, and the other was a chronic aseptic nonunion. MAIN OUTCOME MEASUREMENTS: Healing rate, time to union, functional outcome scores using the Short Musculoskeletal Functional Assessment (SMFA) and pain assessed by the Visual Analog Scale (VAS). RESULTS: The initial average defect size for patients treated with the induced membrane technique was 8.85 cm. Mean follow-up times were similar with 17.06 ± 10.13 months for patients treated with the IMT, and 20.35 ± 16.68. months for patients treated without the technique. Complete union was achieved in 15/17 (88.2%) of segmental bone loss cases treated with the IMT and 17/17 (100%) of cases repaired without the technique at the latest follow up visit. The average time to union for patients treated with the induced membrane technique was 13.0 ± 8.4 months and 9.64 ± 4.7 months for the matched cohort. There were no significant differences in reported outcomes measured by the SMFA or VAS. Patients treated with the induced membrane technique required more revision surgeries than those not treated with an induced membrane. CONCLUSION: Outcomes following treatment of acute bone loss from the diaphysis of long bones with the induced membrane technique produces clinical and radiographic outcomes similar to those of long bone fracture nonunions without bone loss that go on to heal. LEVEL OF EVIDENCE: III.

The prone posteromedial approach to the knee revisited: a safe and effective strategy for posterior tibial plateau fractures.

PURPOSE: To compare outcomes of patients with posterior tibial plateau fractures who underwent repair indirectly with an anterior approach to those who underwent direct repair with a prone "Lobenhoffer" operative approach. METHODS: A total of 44 patients with a posterior column tibial plateau fracture that underwent repair were identified. Twenty-two patients with 22 tibial plateau fractures were fixed using a prone Lobenhoffer approach. They were compared to 22 patients treated with an indirect reduction using a supine approach for similar fracture patterns. Data collection at minimum 1 year included: patient-reported outcome scores (SMFA), patient-reported pain, knee range of motion, complications and need for reoperation. Radiographs were reviewed for knee alignment, residual depression and fracture healing. RESULTS: All demographics were similar between the groups except BMI, which was lower in the prone group (P < 0.05). Fracture type according to age, Schatzker and three-column classification was matched between cohorts. There was no difference in outcomes including: pain, radiographic knee alignment, residual articular depression, functional outcome (SMFA), complications and need for reoperations. Knee flexion at 1 year was greater in the prone group (127.8 vs. 115.8; P = 0.018). In addition, surgical time was less in the prone group (mean 73.7 min vs. 82.3 min; P = 0.015). CONCLUSION: The Lobenhoffer approach with direct reduction of posterior fracture fragments for complex tibial plateau fractures is an excellent option for these injuries. It allowed for faster surgery with improved ultimate knee range of motion in posterior column tibial plateau fractures.

Risk factors for delayed return to work following tibial shaft fracture surgery.

PURPOSE: To determine when patients return to work following operative repair of tibial shaft fractures (TSF) and what risk factors are associated with a delayed return to work (RTW), defined as greater than 180 days after operative repair. METHODS: Retrospective chart review was performed on a consecutive series of TSF patients who underwent operative repair. Time to RTW was based on documented work-clearance communications from the operating surgeon. Patients were divided into 3 groups based on when they returned to work: early (≤ 90 days), average (91-80 days), and late (≥ 180 days). Univariate analysis was performed, and significant variables were included in multinomial logistic regression. RESULTS: There were 168 patients identified. Eighteen were excluded (retired, unemployed, or never returned to work) leaving 150 patients. The average time to RTW for the overall study population was 4.17 ± 2.06 months. There were 39 (26.0%) patients in the early RTW group, 85 (56.7%) in the average RTW group, and 26 (17.3%) in the late RTW group. Patient with high-energy injuries (p = 0.024), open fractures (p = 0.001), initial external-fixation (p = 0.036), labor-intensive job (p = 0.018) and post-operative non-weight bearing status (p = 0.023) all had significantly longer RTW. Multinomial logistic regression including these parameters found a closed fracture was associated with a 1.9 decreased risk of delayed RTW (p = 0.004, 95% CI 0.039-0.533). CONCLUSIONS: Open fractures, initial external-fixation, restricted post-operative weight-bearing and labor-intensive jobs are associated with a delayed RTW following operative repair of TSFs. LEVEL OF EVIDENCE: Therapeutic Level III.

Quadriceps muscle quality and quantity following tibial plateau fracture repair.

PURPOSE: To investigate the qualitative and quantitative changes seen in quadriceps muscles [QM] following tibial plateau fracture and surgery. METHODS: A consecutive series of patients with an isolated tibial plateau fracture presenting to a single academic center were enrolled and prospectively followed. Bilateral knee MRIs were performed preoperatively and 3 and 12 months postoperatively to assess quantity and quality of the quadriceps muscles. All patients underwent tibial plateau operative repair and were made non-weight-bearing for 10 weeks postoperatively then advanced to weight-bearing as tolerated. Functional status assessed via the short musculoskeletal functional assessment (SMFA); knee range of motion [ROM]; vastus medialis oblique [VMO] and vastus lateralis [VL] muscle quantity (axial width, cross sectional area [CSA] and volume) on injured and contralateral limb; VMO, sartorius, semi-membranous and biceps femoris [BF] muscle quality (fat and water content, and proton density fat fraction). All muscle quantitative and qualitative measurements were compared across all time points. RESULTS: Ten patients were included in the final analysis, 6 males and 4 females, with average age of 43.62 ± 16.3 years. While the VMO and VL axial width and CSA were significantly decreased at 3 months preoperatively, this was not statistically significant. There was no significant difference between any QM quantitative measurements at any time points. There was no difference in fat content, water content or PDFF at any time point for the VMO, sartorius, semi-membranous and BF muscles. Regression analysis also showed no association between 12-month SMFA scores and knee ROM with VMO/VL CSA at 1 year. CONCLUSIONS: QM quantity and quality do not significantly change at 3 months and 1 year postoperatively following tibial plateau fracture surgery. LEVEL OF EVIDENCE: Prognostic Level II.

Fracture related infection (FRI) of the upper extremity correlates with poor bone and soft tissue healing.

PURPOSE: The purpose of this study was to evaluate the specific course and complication profile following the development of FRI in the upper extremity. METHODS: An IRB-approved retrospective review was conducted on a consecutive series of operatively managed patients within an academic medical center between 1/2010 and 6/2022. Included patients met the following criteria: (1) upper extremity fracture definitively treated with internal fixation (2) development of criteria for suggestive or confirmatory FRI (as per the FRI Consensus Group) and (3) age ≥ 18 years. Baseline demographics, medical history, injury information, infection characteristics, hospital quality measures, and outcomes were recorded. A 3:1 propensity-matched control cohort of patients without FRI was obtained using the same dataset. Univariable analysis was performed to compare the outcomes (rate of nonunion, time to bone healing, need for soft tissue coverage, patient reported joint stiffness at final follow-up) of the FRI vs Non-FRI cohorts. RESULTS: Of 2827 patients treated operatively for an upper extremity fracture, 43 (1.53%) met criteria for suggestive of confirmatory FRI. The successful propensity match (43 FRI, 129 Non-FRI) revealed no differences in demographics, baseline health status, or fracture location. FRI patients underwent more reoperations (p < 0.001), experienced an increased rate of removal of hardware (p < 0.001), and were admitted more frequently following index operation (p < 0.001). The FRI cohort had higher rates of fracture nonunion (p = 0.003), and a prolonged mean time to bone healing in months (8.37 ± 7.29 FRI vs. 4.14 ± 5.75 Non-FRI, p < 0.001). Additionally, the FRI cohort had a greater need for soft tissue coverage throughout their post-operative fracture treatment (p = 0.014). While there was no difference in eventual bone healing (p = 0.250), FRI patients experienced a higher incidence of affected joint stiffness at final follow-up (p < 0.001). CONCLUSION: Patients who develop an FRI of the upper extremity undergo more procedures and experience increased complications throughout their treatment, specifically increased joint stiffness. Despite this, ultimate outcome profiles are similar between patients who experience FRI and those who do not following operative repair of an upper extremity fracture. LEVEL OF EVIDENCE: III.

Under pressure: symptomatic pulmonary hypertension is a predictor of poor outcome following hip fracture.

INTRODUCTION: Pulmonary hypertension (PHTN) is associated with increased morbidity and mortality in noncardiac surgery and elective surgery. This population of patients has a low physiological reserve and is prone to cardiac arrest as a result. This study aims to identify the impact that PHTN has on outcomes among geriatric hip fracture patients. METHODS: A 3:1 propensity-score-matched retrospective case (PHTN)-control (no PHTN [N]) study of hip fracture patients from 2014 to 2022 was performed. Patients were matched utilizing propensity score matching of a validated geriatric trauma risk assessment tool (STTGMA). All patients were reviewed for hospital quality measures and outcomes. Comparative univariable and multivariable analyses were conducted between the two matched cohorts. A sub-analysis compared patients across PHTN severity levels (mild, moderate, severe) based on pulmonary artery systolic pressures (PASP) as measured by transthoracic echocardiogram. RESULTS: PHTN patients (n = 67) experienced a higher rate of inpatient, 30-day, and 1-year mortality, major complications, and 90-day readmissions as compared to the N cohort (n = 201). PHTN patients with a PASP > 60 experienced a significantly higher rate of major complications, need for ICU, longer admission length, and worse 1-year functional outcomes. Pulmonary hypertension was found to be independently associated with a 3.5 × higher rate of 30-day mortality (p = 0.016), 2.7 × higher rate of 1-year mortality (p = 0.008), 2.5 × higher rate of a major inpatient complication (p = 0.028), and 1.2 × higher rate of 90-day readmission (p = 0.044). CONCLUSION: Patients who had a prior diagnosis of pulmonary hypertension before sustaining their hip fracture experienced significantly worse inpatient and post-discharge outcomes. Those with a PASP > 60 mmHg had worse outcomes within the PHTN cohort. Providers must recognize these at-risk patients at the time of arrival to adjust care planning accordingly. LEVEL OF EVIDENCE: III.

Periprosthetic fracture following arthroplasty for femoral neck fracture: is a cemented stem protective?

BACKGROUND: Periprosthetic femoral fractures (PFF) carry significant morbidity following arthroplasty for femoral neck fracture (FNF). This study assessed fracture complications following arthroplasty for FNF and the effect of cement fixation of the femoral component on intraoperative and post-operative PFF. METHODS: Between February 2014 and September 2021, 740 patients with a FNF who underwent arthroplasty were analyzed for demographics, surgical management, use of cement for fixation of the femoral component, and subsequent PFF. Variables were compared with Mann-Whitney or Chi-square as appropriate. Multivariate logistic regression was used to assess independent risk factors associated with intraoperative or post-operative PFF. RESULTS: There were 163 THAs (41% cemented) and 577 HAs (95% cemented). There were 28 PFFs (3.8%): 18 post-operative and 10 intraoperative. Fewer post-operative PFFs occurred with cemented stems (1.63% vs. 6.30%, p = 0.002). Mean time from surgery to presentation with post-operative PFF was 14 months (0-45 months). Mean follow-up time was 10.3 months (range: 0-75.7 months). In multivariate regression, use of cement and THA was independently associated with decreased post-operative PFF (cement: OR 0.112, 95% CI 0.036-0.352, p < 0.001 and THA: OR 0.249, 95% CI 0.064-0.961, p = 0.044). More intraoperative fractures occurred during THA (3.68% vs. 0.69%, p = 0.004) and non-cemented procedures (5.51% vs. 0.49%, p < 0.001). In multivariate regression, use of cement was protective against intraoperative fracture (OR 0.100, CI 0.017-0.571, p = 0.010). CONCLUSIONS: In patients with a FNF treated with arthroplasty, cementing the femoral component is associated with a lower risk of intraoperative and post-operative PFF. Choice of procedure may be based on patient factors and surgeon preference.

No Differences Between White and Non-White Patients in Terms of Care Quality Metrics, Complications, and Death After Hip Fracture Surgery When Standardized Care Pathways Are Used.

BACKGROUND: Many initiatives by medical and public health communities at the national, state, and institutional level have been centered around understanding and analyzing critical determinants of population health with the goal of equitable and nondisparate care. In orthopaedic traumatology, several studies have demonstrated that race and socioeconomic status are associated with differences in care delivery and outcomes of patients with hip fractures. However, studies assessing the effectiveness of methods to address disparities in care delivery, quality metrics, and complications after hip fracture surgery are lacking. QUESTIONS/PURPOSES: (1) Are hospital quality measures (such as delay to surgery, major inpatient complications, intensive care unit admission, and discharge disposition) and outcomes (such as mortality during inpatient stay, within 30 days or within 1 year) similar between White and non-White patients at a single institution in the setting of a standardized hip fracture pathway? (2) What factors correlate with aforementioned hospital quality measures and outcomes under the standardized care pathway? METHODS: In this retrospective, comparative study, we evaluated the records of 1824 patients 55 years of age or older with hip fractures from a low-energy mechanism who were treated at one of four hospitals in our urban academic healthcare system, which includes an orthopaedic tertiary care hospital, from the initiation of a standardized care pathway in October 2014 to March 2020. The standardized 4-day hip fracture pathway is comprised of medicine comanagement of all patients and delineated tasks for doctors, nursing, social work, care managers, and physical and occupational therapy from admission to expected discharge on postoperative day 4. Of the 1824 patients, 98% (1787 of 1824) of patients who had their race recorded in the electronic medical record chart (either by communicating it to a medical provider or by selecting their race from options including White, Black, Hispanic, and Asian in a patient portal of the electronic medical record) were potentially eligible. A total of 14% (249 of 1787) of patients were excluded because they did not have an in-state address. Of the included patients, 5% (70 of 1538) were lost to follow-up at 30 days and 22% (336 of 1538) were lost to follow-up at 1 year. Two groups were established by including all patients selecting White as primary race into the White cohort and all other patients in the non-White cohort. There were 1111 White patients who were 72% (801) female with mean age 82 ± 10 years and 427 non-White patients who were 64% (271) female with mean age 80 ± 11 years. Univariate chi-square and Mann-Whitney U tests of demographics were used to compare White and non-White patients and find factors to control for potentially relevant confounding variables. Multivariable regression analyses were used to control for important baseline between-group differences to (1) determine the correlation of White and non-White race on mortality, inpatient complications, intensive care unit (ICU) admissions, and discharge disposition and (2) assess the correlation of gender, socioeconomic status, insurance payor, and the Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) trauma risk score with these quality measures and outcomes. RESULTS: After controlling for gender, insurer, socioeconomic status and STTGMA trauma risk score, we found that non-White patients had similar or improved care in terms of mortality and rates of delayed surgery, ICU admission, major complications, and discharge location in the setting of the standardized care pathway. Non-White race was not associated with inpatient (odds ratio 1.1 [95% CI 0.40 to 2.73]; p > 0.99), 30-day (OR 1.0 [95% CI 0.48 to 1.83]; p > 0.99) or 1-year mortality (OR 0.9 [95% CI 0.57 to 1.33]; p > 0.99). Non-White race was not associated with delay to surgery beyond 2 days (OR = 1.1 [95% CI 0.79 to 1.38]; p > 0.99). Non-White race was associated with less frequent ICU admissions (OR 0.6 [95% CI 0.42 to 0.85]; p = 0.03) and fewer major complications (OR 0.5 [95% CI 0.35 to 0.83]; p = 0.047). Non-White race was not associated with discharge to skilled nursing facility (OR 1.0 [95% CI 0.78 to 1.30]; p > 0.99), acute rehabilitation facility (OR 1.0 [95% CI 0.66 to 1.41]; p > 0.99), or home (OR 0.9 [95% CI 0.68 to 1.29]; p > 0.99). Controlled factors other than White versus non-White race were associated with mortality, discharge location, ICU admission, and major complication rate. Notably, the STTGMA trauma risk score was correlated with all endpoints. CONCLUSION: In the context of a hip fracture care pathway that reduces variability from time of presentation through discharge, no differences in mortality, time to surgery, complications, and discharge disposition rates were observed beween White and non-White patients after controlling for baseline differences including trauma risk score. The pathway detailed in this study is one iteration that the authors encourage surgeons to customize and trial at their institutions, with the goal of providing equitable care to patients with hip fractures and reducing healthcare disparities. Future investigations should aim to elucidate the impact of standardized trauma care pathways through the use of the STTGMA trauma risk score as a controlled confounder or randomized trials in comparing standardized to individualized, surgeon-specific care. LEVEL OF EVIDENCE: Level III, therapeutic study.

Increasing Diversity in Orthopaedics: The Problem, Strategies, and Solutions.

It is important to educate and equip the orthopaedic community with tools to address health care disparities and improve orthopaedic specialty recruitment for racial minorities. How patients and providers are affected by systemic racism in healthcare and what that means in orthopaedic surgery, methods to identify bias and improve access to orthopaedic care for racial minorities, and how to structure a program and department environment to encourage and promote diversity are important topics of discussion.

Primary versus conversion reverse total shoulder arthroplasty for complex proximal humeral fractures in elderly patients: a retrospective comparative study.

BACKGROUND: The purpose of this study was to compare clinical, implant-related, and patient-reported outcomes of shoulders undergoing conversion to reverse total shoulder arthroplasty (rTSA) following previous open reduction-internal fixation vs. shoulders undergoing rTSA as a primary treatment modality for acute proximal humeral fractures (PHFs) in patients aged ≥65 years. METHODS: We performed a retrospective analysis of a prospectively collected cohort of patients who underwent primary rTSA for PHFs vs. a cohort who underwent conversion arthroplasty with rTSA following fracture repair between 2009 and 2020. Outcomes were assessed preoperatively and at latest follow-up. Demographic characteristics and outcomes were analyzed between cohorts using conventional statistics, as well as stratification by minimal clinically important difference and substantial clinical benefit thresholds where applicable. RESULTS: In total, 406 patients met the study criteria, of whom 322 underwent primary rTSA for PHF and 84 underwent conversion rTSA after failed PHF open reduction-internal fixation. The conversion rTSA cohort was, on average, 7 years younger than the primary rTSA cohort (65 ± 10 years vs. 72 ± 9 years, P < .001). The follow-up periods were similar between the cohorts, with an average of 47.1 months (range, 24-138 months). The percentages of Neer 3-part (41.9% vs. 45.2%) and 4-part (49.1% vs. 46.4%) PHFs were similar (P > .99). The primary rTSA cohort achieved higher forward elevation, external rotation, and patient-reported outcome measurements including Simple Shoulder Test, American Shoulder and Elbow Surgeons, University of California-Los Angeles, Constant, Shoulder Arthroplasty Smart, and Shoulder Pain and Disability Index scores at a minimum of 24 months postoperatively (P < .05 for all). Patient satisfaction was higher in the primary rTSA group than in the conversion rTSA cohort (P = .002). Patient-reported outcome measures uniformly favored the primary rTSA cohort, rising to the level of statistical significance for forward elevation, American Shoulder and Elbow Surgeons score, and Shoulder Pain and Disability Index score (P < .05) relative to substantial clinical benefit. The adverse event rate and revision rate in the conversion rTSA cohort were higher than those in the primary rTSA cohort (26.2% vs. 2.5% [P < .001] and 8.3% vs. 1.6% [P = .001], respectively). At 10 years postoperatively, the revision-free implant survival rate was significantly lower in the conversion cohort compared with the primary cohort (66% vs. 94%, P = .012). Finally, the hazard ratio of revision was 3.69 in the conversion rTSA cohort compared with only 1.0 in the primary rTSA cohort. CONCLUSION: This study demonstrates that elderly patients who undergo rTSA as a conversion procedure following previous osteosynthesis do not fare as well as those treated with rTSA for acute displaced PHFs. Conversion rTSA patients report lower patient satisfaction and have significantly restricted range of shoulder motion, a higher risk of complications, a higher risk of revision, poorer patient-reported outcomes, and a shorter implant survival rate at 10 years compared with patients undergoing acute rTSA.

Skilled Nursing Facility Following Hip Fracture Arthroplasty Diminishes Care "Value".

BACKGROUND: Value is defined as outcome/cost. The purpose of this study was to analyze differences in the lengths of care, outcomes, and costs between skilled nursing facilities (SNFs) and home with health services (HHS) for patients treated with arthroplasty for femoral neck fracture (FNF). METHODS: Between October 2018 and September 2020, 192 patients eligible for the Comprehensive Care for Joint Replacement bundle program treated for a displaced FNF with total hip arthroplasty (THA) or hemiarthroplasty (HA) and discharged to SNF or HHS were analyzed for demographics, comorbidities, postoperative outcomes, costs of care, and discharge rehabilitation details. Variables were compared using chi-squared or t-tests as appropriate. There were 60 (31%) patients discharged to HHS (37% THA and 63% HA) and 132 (69%) patients discharged to SNF (14% THA and 86% HA). Patients discharged to SNF were older (P < .01), had lower Risk Assessment and Prediction Tool scores (P < .01), had higher comorbidity scores (P = .011), and had longer posthospitalization care (P < .01). RESULTS: There were no differences in rates of inpatient minor complications (P = .520), inpatient major complications (P = .119), Intensive Care Unit admissions (P = .193), or readmissions within 30 (P = .690) and 90 days (P = .176). Costs of care at a SNF were higher than HHS (P < .01). In multivariate regressions, a lower Risk Assessment and Prediction Tool score was associated with discharge to SNF (odds ratio 0.69, 95% confidence interval 0.58-0.83, P < .001). CONCLUSION: Among Comprehensive Care for Joint Replacement bundle patients treated for a displaced FNF with arthroplasty, discharge with HHS may be a more cost-effective option than discharge to a SNF that does not increase risk of readmission in medically appropriate patients.

Microbiome of infected fracture nonunion: Does it affect outcomes?

BACKGROUND: Infected fracture nonunions often require prolonged treatment and recovery courses. It is unclear whether the bacterial microbiome influences the time to healing as well as the eradication of infection. The goals of this study are (1) to assess the bacterial microbiome affecting infected nonunions and (2) to evaluate the effects of bacterial speciation on associated outcomes. METHODS: Between 2006 and 2022, data from 551 adult patients from a single academic institution who presented with a fracture nonunion were analyzed retrospectively for infection. All patients underwent revision surgery with three sets of cultures obtained intra-operatively. Patients with significant intra-operative cultures were grouped into gram-positive and gram-negative culture cohorts. These patients were managed with a standardized protocol involving surgical debridement, nonunion site fixation, and culture-directed antibiotic treatment. Primary outcome was time to fracture union. Secondary outcomes included number of re-operations and eventual amputation or reconstructive surgery. RESULTS: 56 nonunion patients (10 %) were diagnosed with an infected nonunion (44 g-positive, 12 g-negative). Of these, 3 g-positive patients received an amputation or arthroplasty procedure prior to fracture union, and seven were lost to follow-up. There were no significant differences in age, gender, or nonunion site between cohorts. Most nonunions occurred in the lower extremity. The most common bacteria were staph species (54.3 %). 36 g-positive and 10 g-negative patients achieved fracture union. Time to union was on average 158.4 days longer in the gram-negative cohort-but did not reach statistical significance (446.8 days gram-positive, 662.3 days gram-negative, p = 0.69). There was no difference in re-operation rates (1.9 % gram-positive, 2.2 % gram-negative, p = 0.84). CONCLUSIONS: Patients with infected nonunions had wide-ranging bacterial contamination that were treated successfully using a standardized protocol. However, patients with any gram-negative culture trended toward a delay in time to union.

Patient obesity is associated with severity of proximal humerus fractures, not outcomes.

PURPOSE: The purpose of this study is to evaluate the effect of obesity on the outcome of operatively treated proximal humerus fractures. METHODS: Between December 2003 and October 2020, 240 patients with proximal humerus fractures requiring surgery were prospectively followed and classified according to the international AO/Orthopedic Trauma Association (AO/OTA) and Neer classifications. Patients' body mass indexes (BMI) were calculated and used to identify two groups, BMI ≥ 30 kg/cm (obese) and < 30 kg/cm (non-obese). Independent t tests were used for statistical analysis of continuous variables and χ2 tests for categorical variables. Regression analysis was performed to determine if BMI was a predictor of fracture pattern severity as determined by the AO/OTA classification. RESULTS: Overall, 223 patients who sustained proximal humerus fractures were analyzed. Patient age at time of injury was 60.5 ± 13.7 years. There were 67 AO/OTA 11A, 79 AO/OTA 11B, and 77 AO/OTA 11C fracture types. Seventy-two patients (32.3%) were obese. No significant differences were seen between groups in regard to demographic variables, Neer classification, or functional and clinical outcomes as determined by DASH scores and shoulder ROM, respectively. Statistical analyses confirmed that obesity is associated with more severe fracture patterns of the proximal humerus as categorized by the AO/OTA classification. An independent t test confirmed that BMI was significantly higher in the complex fracture group based on the AO/OTA classification (p = 0.047). Regression analysis also demonstrated that age (p = 0.005) and CCI (p = 0.021) were predictors of more severe fractures, while BMI approached significance (p = 0.055) based on the AO/OTA classification. CONCLUSION: A significantly higher incidence of complex proximal humerus fracture patterns is observed in patients with higher body mass indexes based on the AO/OTA classification. Age and CCI are also associated with more severe fracture patterns of the proximal humerus as determined by the AO/OTA classification. No differences were seen in outcomes or complication rates between obese patients and non-obese patients. LEVEL OF EVIDENCE: Level III.

Does mechanism of injury impact the outcome of operative fixation of geriatric proximal humerus fractures.

BACKGROUND: The purpose of this study is to determine the effects of energy mechanism on outcomes following repair of proximal humerus fractures (PHF) in the middle aged and geriatric population. METHODS: Two hundred sixty-nine patients who presented to our academic medical center between 2006 and 2020, and underwent operative treatment of a proximal humerus fracture were prospectively enrolled in an IRB-approved database. Patients above 55 were divided into high energy (motor vehicle accident, pedestrian struck, or fall > 2 stairs) or low energy mechanisms (fall from standing or < 2 stairs). Of 97 patients with complete documentation and follow-up, 72 were included in the low velocity (LV) group and 25 were included in the high velocity (HV) group. Demographic information, primary injury details, healing and time to union, range of motion (ROM), complications, and need for reoperation were assessed at initial presentation and subsequent follow-up appointments. RESULTS: Mean age, BMI, and gender were significantly different between the LV and HV cohorts (p = 0.01, 0.04, 0.01). OTA/AO fracture patterns were similar between the groups. (p = 0.14). Bony healing and complications occurred with similar frequency between groups (p = 1.00, 0.062). The most common complications in the LV and HV groups included avascular necrosis (9.7%, 16.0%), and screw penetration (4.2%, 12.0%), while the HV group also had rotator cuff issues including weakness and tendonitis (12.0%). There was no significant difference in need for reoperation between cohorts (p = 0.45). Time to healing, shoulder ROM, and DASH scores did not differ between each group. CONCLUSIONS: Energy and mechanism demonstrates similar outcomes in operatively treated proximal humerus fractures. These factors should not play a role in decisions for surgery in these patients and can help guide patient expectations.

Nonunion of conservatively treated humeral shaft fractures is not associated with anatomic location and fracture pattern.

INTRODUCTION: Humeral shaft fractures make up 1-3% of all fractures and are most often treated nonoperatively; rates of union have been suggested to be greater than 85%. It has been postulated that proximal third fractures are more susceptible to nonunion development; however, current evidence is conflicting and presented in small cohorts. It is our hypothesis that anatomic site of fracture and fracture pattern are not associated with development of nonunion. MATERIALS AND METHODS: In a retrospective cohort study, 147 consecutive patients treated nonoperatively for a humeral shaft fracture were assessed for development of nonunion during their treatment course. Their charts were reviewed for demographic and radiographic parameters such as age, sex, current tobacco use, diabetic comorbidity, fracture location, fracture pattern, AO/OTA classification, and need for intervention for nonunion. RESULTS: One hundred and forty-seven patients with 147 nonoperatively treated humeral shaft fractures were eligible for this study and included: 39 distal, 65 middle, and 43 proximal third fractures. One hundred and twenty-six patients healed their fractures by a mean 16 ± 6.4 weeks. Of the 21 patients who developed a nonunion, two were of the distal third, 10 of the middle third, and nine were of the proximal third. In a binomial logistic regression analysis, there were no differences in age, sex, tobacco use, diabetic comorbidity, fracture pattern, anatomic location, and OTA fracture classification between patients in the union and nonunion cohorts. CONCLUSIONS: Fracture pattern and anatomic location of nonoperatively treated humeral shaft fractures were not related to development of fracture nonunion.

The standardized exploration of the radial nerve during humeral shaft fixation reduces the incidence of iatrogenic palsy.

BACKGROUND: The purpose of this study is to determine if a standardized protocol for radial nerve handling during humeral shaft repair reduces the incidence of iatrogenic nerve palsy post operatively. METHODS: Seventy-three patients were identified who underwent acute or reconstructive humeral shaft repair with radial nerve exploration as part of the primary procedure for either humeral shaft fracture or nonunion. All patients exhibited intact radial nerve function pre-operatively. A retrospective chart review and analysis identified patients who developed a secondary radial nerve palsy post-operatively. In each case, the radial nerve was identified and mobilized for protection, regardless of whether the implant necessitated the extensile exposure. RESULTS: Fractures were classified according to AO/OTA guidelines and included 23 Type 12A, 11 Type 12B, and 3 Type 12C. Eight patients had periprosthetic fractures and 28 fractures could not be classified. All patients in the cohort were fixed with locking plates. Surgery was indicated for 36 patients with humeral nonunions and 37 patients with acute humeral shaft fractures. Of the 73 patients, 2 (2.7%) developed radial nerve palsy following surgery, one from the posterior approach and one from the anterolateral approach. Both patients exhibited complete recovery of radial nerve function by 6-month follow-up. No significant differences (p > 0.05) were found in any demographic or surgical details between those with and without radial nerve injury. CONCLUSIONS: Nerve exploration identification and protection leads to a low incidence of transient radial nerve palsy compared to the rate reported in the current literature (2.7% compared to 6-24%). Thus, radial nerve exploration and mobilization should be considered when approaching the humeral shaft for acute fracture and nonunion repairs. LEVEL OF EVIDENCE: Level III.

Total hip arthroplasty for hip fractures in patients older than 80 years of age: a retrospective matched cohort study.

INTRODUCTION: Increasing age and hip fractures are considered risk factors for post-operative complications in total hip arthroplasty (THA). Consequently, older adults undergoing THA due to hip fracture may have different outcomes and require additional healthcare resources than younger patients. This study aimed to identify the influence of age on discharge disposition and 90-day outcomes of THA performed for hip fractures in patients ≥ 80 years to those aged < 80. MATERIALS AND METHODS: A retrospective review of 344 patients who underwent primary THA for hip fracture from 2011 to 2021 was conducted. Patients ≥ 80 years old were propensity-matched to a control group < 80 years old. Patient demographics, length of stay (LOS), discharge disposition, and 90-day post-operative outcomes were collected and assessed using Chi-square and independent sample t tests. RESULTS: A total of 110 patients remained for matched comparison after propensity matching, and the average age in the younger cohort (YC, n = 55) was 67.69 ± 10.48, while the average age in the older cohort (OC, n = 55) was 85.12 ± 4.77 (p ≤ 0.001). Discharge disposition differed between the cohorts (p = 0.005), with the YC being more likely to be discharged home (52.7% vs. 27.3%) or to an acute rehabilitation center (23.6% vs. 16.4%) and less likely to be discharged to a skilled nursing facility (21.8% vs. 54.5%). 90-day revision (3.6% vs. 1.8%; p = 0.558), 90-day readmission (10.9% vs. 14.5%; p = 0.567), 90-day complications (p = 0.626), and 90-day mortality rates (1.8% vs 1.8%; p = 1.000) did not differ significantly between cohorts. CONCLUSION: While older patients were more likely to require a higher level of post-hospital care, outcomes and perioperative complication rates were not significantly different compared to a younger patient cohort. Payors need to consider patients' age in future payment models, as discharge disposition comprises a large percentage of post-discharge expenses. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

Screws Alone for Acute Lisfranc Injuries Fixed Without Arthrodesis: A Better "Value" Than Plating in the Short Term.

This study compares outcomes of patients with Lisfranc injuries treated with screw only fixation constructs to those treated with dorsal plate and screw constructs. Seventy patients who underwent surgical treatment for acute Lisfranc injury without arthrodesis and minimum 6-month (mean >1-year) follow-up were identified. Demographics, surgical information, and radiographic imaging were reviewed. Cost data were compared. The primary outcome measure was the American Orthopedic Foot and Ankle Surgery (AOFAS) midfoot score. Univariate analysis through independent sample t tests, Mann-Whitney U, and chi-squared compared the populations. Twenty-three (33%) patients were treated with plate constructs and 47 (67%) with screw only fixation. The plate group was older (49 ± 18 vs 40 ± 16 years, p = .029). More screw constructs treated isolated medial column injuries compared to plate constructs (92% vs 65%, p = .006). At latest follow-up (mean 14 ± 13 months), all tarsometatarsal joints were aligned. There was no difference in AOFAS midfoot scores. Plate patients experienced longer operations (131 ± 70 vs 75 ± 31 minutes, p < .001) and tourniquet time (101 ± 41 vs 69 ± 25 minutes, p = .001). Plate constructs were more expensive than screw ($2.3X ± $2.3X vs $X ± $0.4X, p < .001) ($X is the mean cost of screws alone). Plate patients had a higher incidence of wound complications (13% vs 0%, p = .012). Treatment of Lisfranc fracture dislocation injuries with screws only demonstrated a higher value procedure as similar outcomes were found amidst lower implant costs. Screw only fixation required a shorter operative and tourniquet time with less frequent wound complications. Screw only fixations proved mechanically sound enough to achieve goals of repair without inferior outcomes.

Preoperative echocardiogram does not increase time to surgery in hip fracture patients with prior percutaneous coronary intervention.

BACKGROUND: The purpose of this study was to (1) assess the effect of preoperative echocardiogram on time to surgery and (2) assess the outcomes of patients with a previous percutaneous coronary intervention (PCI). METHODS: Demographic, clinical, quality and cost data were obtained and a validated risk predictive tool (STTGMA) was calculated for each of a consecutive series of hip fracture patients. Comparative analyses of patients who had an echocardiogram prior to surgery or a PCI prior to hospitalization were performed. RESULTS: Between 2014 and 2020, 2625 patients presented to our institution with a hip fracture. From this cohort 471 patients underwent a preoperative transthoracic echocardiogram (TTE), 30 who had a history of a PCI, and an additional 26 who had a history of PCI but did not undergo a preoperative TTE. Those undergoing a preoperative TTE had similar time (days) to surgery (1.73 vs 1.77, p = 0.86) and 30-day mortality (4% vs 7%, p = 0.545) regardless of PCI history. PCI patients who underwent a preoperative TTE experienced increased rates of 1-year mortality (27% vs 10%, p = 0.007) and major complications (23% vs 12%, p = 0.08) compared to those without a PCI history. PCI patients undergoing a preoperative TTE had a similar time (days) to surgery (1.77 vs 1.48, .p = 0.397) compared to PCI patients without a preoperative TTE. Patients who underwent a preoperative TTE had higher rates of 90-day readmission (31.0% vs 8.0%, p = 0.047) and 1-year mortality (26.7% vs 3.8%, p = 0.029). CONCLUSIONS: Having a preoperative TTE does not affect surgical wait times in hip fracture patients regardless of PCI history, but it may not improve mortality outcomes or reduce postoperative complications in patients with a history of a PCI.